Cost effectiveness of an ICU-run adult ECMO program Jefferson University ECMO experience Hitoshi Hirose, MD, PhD. Nicholas Cavarocchi MD Thomas Jefferson University

Disclosure None

ECMO program Shortage of “ECMO specialists” ELSO to form new guidelines: Board certified nurses who have at least one year of critical care experience can be trained as ECMO specialists

ECMO program ECMO program expansion Financial concerns However, the financial concerns were not weighed against the long-term cost benefit of training nurses as ECMO specialists.

Objective We aim to describe our experiences in implementing a new cost-reducing ECMO model in an ICU setting involving multidisciplinary providers (registered nurses, midlevel providers and intensivists) as ECMO specialists.

Non standard ECMO program Prior to June 2010 Number of average ECMO: 5-8/year Duration of ECMO: a few days, max 1 week ECMO triage: CT surgeon ECMO placement: CT surgeon ECMO circuit: Biomedicus and Avecor oxygenator Monitoring personnel: perfusionist bed side Monitoring: A-line, Swan, back pressure monitor, Pulse ox, ACT, Individualized care plan

Non standard ECMO program Prior to July 2010 High mortality High complications

New standard ECMO After June 2010 Average number of ECMO: 20-40/year Average duration of ECMO: 8-10 days ECMO triage: ICU attending ECMO placement: ICU attending, perfusion, mid levels, RNs In ICU, Cath lab, OR based on risks. ECMO circuit: Rotaflow pump ECMO oxygenator: Quadrox D

New standard ECMO After June 2010 Monitoring personnel: multidisciplinary providers Perfusionist should be available for call If central cannulation, perfusion in house (not need to be at bedside).

New standard ECMO After June 2010 Standard monitoring: A-line, EKG, upper extremity pulse ox No swan Distal perfusion cannula Cerebral and lower ext tissue oximetry PTT, heparin protocol Standard securing cannula

Multidisciplinary providers The education platform: Didactic sessions Hands-on sessions Regular competency tests Competency checklist Allocation of dedicated space Development of algorithms Recruitment of new specialists

Role of new specialists. Continuous bedside perfusion monitoring. Assess the ECMO circuit Assist the perfusionist in initiating ECMO No changes in nursing ratio (1:1 nurse to patient ratio) PRN Perfusionists’ services

Integration of the model Phase I (first year of program) Perfusionist at bedside with 2:1 RN ratio Education process in progress Didactic sessions Hands-on session Competency checklist Development of algorithms

Integration of the model Phase II (second year of program) PRN Perfusionist Daily perfusionist round 1:1 ratio of new ECMO specialist

Patient characteristics

Cost analysis Phase I Cost N $ Total Fee per ECMO set up $834 n=28 $23,352 Fee per hour $101 5712 h $576,912 Total ECMO cost $600,264 Phase II Fee per monthly retainer $19,500 n=12 $234,000 Total ECMO cost $234,000 Total Saving $ $366,264

Complications Phase I Phase II P Mortality 42% 59% 0.23 Circuit disconnect 1 1 0.72 Cannula dislodge 0 1 0.43

Conclusions We demonstrated that the ICU run ECMO model decreases hospital cost by reducing the cost of continuous bedside perfusion support with no loss in safety and outcomes.

Thank you Jefferson CVICU team Drs. Cavarocchi, Pitcher, Qiong Midlevel: Miessau, Karbowski, Kelly Perfusions: Tropea, Walsh Nursing educations: Mundy, Byrne, Wallace All CVICU RNs and Techs

Check list

Competency check list Critical behavior ECMO circuit 1. Reviews and follows nursing procedure-care of the patient with adult ECMO ECMO basics 1. States location, purpose, indications and contraindications of use. 2. Identifies resources to troubleshoot 3. Describes the process of percutaneous cannulation and ECMO start up 4. Describes the difference between venoveno and venoarterial ECMO ECMO pump/cart 1. States location of the ECMO cart 2. States contents of the ECMO cart 3. Identifies that the ECMO cart has had a daily check completed 4. Identifies the on/off power switch 5. Identifies the battery indicator 6. Identifies the display screen 7. Identifies the pump and oxygenator 8. Identifies the flow sensor ECMO circuit 1. States location of backup circuit and states procedures for obtaining replacement/back-up equipment 2. Demonstrates the appropriate technique in assessing the ECMO circuit and keeps circuit visible Patient care 1. Performs a thorough patient assessment, (respiratory, neurological, cannula site, and vital signs) and the interpretation of the assessment 2. Discuss the interpretation of clinical signs and symptoms appropriately and communicates with physicians 3. Demonstrates or describes the relationship of the ECMO blood flow to oxygen delivery and oxygen consumption 4. Reviews the relationship of sweep gas and carbon dioxide removal

Competency check list Patient care continued Troubleshooting 5. Evaluates the interpretation of the patient arterial blood gas and the appropriate response with sweep 6. Documents on ECMO flow sheet 7. Identifies the correct interventions for laboratory values 8. Maintains hourly in/out record status Troubleshooting 1. States procedures for protecting patient when equipment fails 2. Demonstrates the ability to clamp the line and move pump to back up 3. Demonstrates hand cranking of the pump 4. Performs the various interventions in the management of hemorrhage (example: cannulae site, access sites, gastrointestinal tract, etc.) 5. Discuss possible complications and emergency scenarios including device failure, bleeding, lower limb ischemia, decreased flow, chatter, arrhythmia, decreased cerebral oximetry or mix venous saturation.